Date of Birth*
Current Age*
Phone Number*
Have you previously served in the Foster Grandparent Program? Yes  No  
If Yes, where? How long?
Briefly explain why you feel you would be a successful Foster Grandparent:
Physical Health Condition: Excellent  Good  Fair   Poor  
Do you have any chronic health conditions that we should be aware of? (i.e., diabetes, insulin-dependent diabetes, heart condition, anti-seizure medication)

Please answer the following general information questions so we may know you better:

Previous Major Occupation(s)?
Years of school completed?
Speak any language other than English?
Speak any language other than English?
Hobbies, interests or special skills?
Memberships in clubs or organizations?
Any family members or friends who are or have been Foster Grandparents? Yes  No  
If Yes, may we ask their name(s)?
Any additional information that you would like to share?
Do you drive and/or have your own vehicle? Yes  No  
If No, how will you reach your assigned volunteer location?

Volunteer Location Preferences -- Select your preference below:

Rapides Parish Rapides Parish School Classroom Tutoring   
       Junior High    
       High School   
       No Preference 

Rapides Parish Head Start Classroom Tutoring   
LA Special Education Center    
Grant Parish Grant Parish School Classroom Tutoring  
       Junior High      
       High School   
       No Preference 

Grant Parish Head Start Classroom Tutoring  

Volunteer Time Preferences - Select your preference below:

Mornings  Afternoons  
Do you have email access? Yes  No  
If Yes, may we send you emails periodically? Yes  No  
Email Address:
Do you have any criminal convictions (other than parking violations or juvenile offenses)? Yes  No  
If yes, please describe:

Do you authorize the Foster Grandparent Program to perform or arrange for a criminal history check?

This is done in order to comply with federal program requirements* Yes   No  

Please provide two character references who are not relatives:

Address / City
Phone Number
Address / City
Phone Number

Emergency Contact:

Relationship to you:
Phone Number(s):

Primary Care Physician or Medical Facility:

Telephone Number(s):

Please submit this application and the income eligibility form,
by mail or in person to:
             Carrie Spriggins - Foster Grandparent Director
CENLA Area Agency on Aging, Inc.
1423 Peterman Drive
Alexandria, LA 71301